Background: To reduce the reliance on clinical judgment for the regulation of sports-related traumatic brain injury, identifying and measuring objective to biofluid biomarkers can provide important insight into the diagnosis (Determining the type and origin of a disorder) and prognosis (Determining the chance of survival of a disorder) of SR-TBIs. A biomarker is a qualitative or quantitative measurement that provides a measure of a subject’s physiological or pathological condition at a specific time or during a disease state. Recent literature has suggested that biomarkers can help in the screening of patients exhibiting symptoms of mild traumatic brain injury (mTBI). Despite insights from recent research, it is not clear whether biomarkers and assessments of sports-related TBI are well-aligned. The objective of this study sought to review the current literature on predictive values of biomarkers: glial fibrillary acidic protein (GFAP), calcium channel binding protein S100 subunit beta (S100β), total-tau and neuron-specific enolase (NSE) for sports-related Traumatic Brain Injuries (SR-TBIs) to improve comprehension of biological and clinical contexts that can help evaluate the use of these biomarkers in sports-related TBIs and their potential function. Methods: The study was reported based on guidelines recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA: 2020 Edition) of 8 studies related to the assessment of biomarkers concerning SR-TBI. Literature searches were carried out on PubMed, Google Scholar, ScienceDirect, and ResearchGate. With an evidentiary table, the characteristics of the studies included in the meta-analysis (n = 14 studies) were presented. A significant role for biomarkers in the management of mild traumatic brain injury is suggested by the results of this analysis. From the literature, the significance of biomarkers in SR-TBI was identified along with the biomarkers that can facilitate more accurate clinical decision-making. Results:The initial search resulted in 73 articles, and the application of exclusion criteria and removal of duplicates resulted in the inclusion of 14 articles. Eight of the included studies were ([26], [27], [28], [30], [34], [39], [40], [41]), three were cohort studies ([25], [37], [45]) one was a pilot study [32], one interview, and an observational study [44]. The review was carried out to determine the efficacy of Biomarkers GFAP, S100β, Total-tau, and NSE to help in the screening of mild traumatic brain injury (mTBI) in patients showing symptoms. The focus is on athletes presenting at an emergency department with possible mTBI requiring a CT scan based on the application of a clinical algorithm. A forest plot was utilized, and the studies had low heterogeneity or variability (P Conclusions: It was established that the utility of biofluid biomarkers in the prediction of mild traumatic brain injury due to SRC is significant when the markers are used in large combinations. The four biofluid biomarkers (S100β, total-tau, GFAP, NSE) under study have strong predictive ability for mTBI, and their use can reduce the number of CT scans among TBI patients participating in athletic activities. Although preliminary evidence shows that other diagnostic treatments may help to mitigate traumatic brain injury sequelae, clinical trials are needed to further test their efficacy, specifically with diverse and high-risk populations. Luckily, the research on mTBI biomarkers is rapidly advancing, and should these biomarkers be better established clinically, they could easily hold many important roles.

Blast-induced mild traumatic brain injury (BImTBI) is one of the most common causes of traumatic brain injuries. BImTBI mechanisms are not well identified, as most previous blast-related studies were focused on the visible and fatal injuries. BImTBI is a hidden lesion and long-term escalation of related complications is considered a serious health care challenging due to lack of accurate data required for early diagnosis and intervention. The experimental studies presented in this thesis were performed to investigate aspects of blast shock wave mechanisms that might lead to mild traumatic brain injury. A compressed air-driven shock tube was designed and validated using finite element analysis (FEA) and experimental investigation. Two metal diaphragm types (steel and brass) with three thicknesses (0.127, 0.76, and 0.025mm) were utilized in the shock tube calibration experiment, as a new approach to generate shock wave. The consistency of generated shock waves was confirmed using a statistical assessment of the results by evaluating the shock waves parameters. The analysis results showed that the 0.127mm steel diaphragm induces a reliable shock waveform in the range of BImTB investigations. Evaluation of the shock wave impacts on the brain was examined using two sets of experiments. The first set was conducted using a gel brain model while the second set was performed using a physical head occupied with a gel brain model and supported by a neck model. The gel brain model in both the experimental studies was generated using silicone gel (Sylgard-527). The effects of tested models locations and orientations with respect to the shock tube exit were investigated by measuring the generated pressure wave within the brain model and acceleration. The results revealed that the pressure waveform and acceleration outcomes were greatly affected by the tested model orientations and locations in relation to the path of shock wave propagation. / Thesis / Doctor of Philosophy (PhD)

Recently there has been considerable attention directed towards the increased risk for head injuries that athletes face while participating in high impact sports. Furthermore, there is also heightened interest in the asymptomatic sport related sub-concussive blows, commonly experienced during play, that possibly lead to long term neurological deficits. Purpose: The goal of this study was to investigate retired professional athletes of the Canadian Football League with a history of sport-related concussions, using several advanced MRI methods. The ultimate goal being the identification of any potential synergistic effects between a history of sport-related concussions, and exacerbated cognitive decline later on in life. Materials and Methods: Twenty former professional athletes of the Canadian Football League were scanned using a GE Discovery MR750 3T MRI with a 32-channel RF-coil. Axial FSPGR-3D images were used to define rs-BOLD and DTI scans. Seed based network analysis of the DMN was performed on rs-BOLD data. Voxel-wise tensor fitting of DTI data provided the means for estimating several tensor metrics. Results were normalized through comparison with a database of healthy controls. Potential associations between functional connectivity, white matter integrity, and cortical thickness measures were correlated with retired athlete position and years of professional play. Results: We found widespread cortical thinning in retired CFL subjects, alongside significant increases in axial and mean diffusivity in the corona radiata and splenium and genu of the corpus callosum compared to controls. Seed based correlation analysis of the DMN network revealed interrupted connectivity in retired athletes. Athlete age, po- sition, and number of years played appear to be factors in overall core white matter microstructural integrity. Conclusions: When compared to an age and sex matched control population, differences were observed both in functional and structural con- nectivity, suggesting that even years after retiring the brains of these former athletes still exhibit signs of damage. / Thesis / Master of Applied Science (MASc) / Sport-related concussions affect millions of athletes on a yearly basis in the United States alone. Concussions are often accompanied by short-lived neurological impairments, such as confusion, headaches, dizziness, nausea and memory loss. In addition, there is the potential for development of long term mental health and cognitive impairment. The goal of this work was to identify any neurological changes present in retired athletes of the Canadian Football League, through the use of advanced magnetic resonance imaging techniques evaluating thickness of brain structures, changes in brain activity, and alterations in core microstructure of the brain. Analyzing the results of these techniques revealed changes in a number of brain regions within the retired professional athlete population. These results suggest that a career of high impact sports may lead to short term, in addition to long-term neurological consequences.

The present dissertation details a sequence of studies in mild traumatic brain injury, the progression of its effects on the human brain as recorded by event-related electroencephalography, and potential applications of machine learning algorithms in detecting such effects. The work investigated data collected from two populations (in addition to healthy controls): 1) a recently-concussed adolescent group, and 2) a group of retired football athletes who sustained head trauma a number of years prior to testing. Neurophysiological effects of concussion were assessed across both groups with the same experimental design using a multi-deviant auditory oddball paradigm designed to elicit the P300 and other earlier components. Explainable machine learning models were trained to classify concussed individuals from healthy controls. Cross-validation performance accuracies on the recently-concussed (chapter 4) and retired athletes (chapter 3) were 80% and 85%, respectively. Features showed to be most useful in the two studies were different, motivating a study of potential differences between the different injury-stage/age groups (chapter 5). Results showed event-related functional connectivity to modulate differentially between the two groups compared to healthy controls. Leveraging results from the presented work a theoretical model of mild traumatic brain injury progression was proposed to form a framework for synthesizing hypotheses in future research. / Dissertation / Doctor of Philosophy (PhD)

L’objectif principal de la présente thèse est d’étudier la nature multifactorielle des difficultés attentionnelles que présentent les personnes ayant subi un traumatisme craniocérébral léger (TCCL). Plus spécifiquement, nous avons voulu cerner l’impact des symptômes de douleur, ainsi que de facteurs émotifs et de personnalité, sur le fonctionnement attentionnel de personnes ayant eu un TCCL. Afin d’atteindre cet objectif, cette thèse présente trois articles. Dans le premier article, l’impact cognitif/neuropsychologique de la douleur chronique (DC) et de ses variables psychologiques concomitantes a été examiné par le biais d’une recension des écrits. Le deuxième article présente une étude expérimentale portant sur les relations entre des variables liées à la douleur et à l’affectivité, et le fonctionnement attentionnel de personnes ayant subi un TCCL étant à différents stades de récupération, comparativement à un groupe témoin normal. Enfin, un troisième article décrit une étude expérimentale qui a été menée afin d’explorer les associations entre certains facteurs de personnalité (neuroticisme, extraversion) et l’efficacité attentionnelle chez des participants normaux, ainsi que chez des personnes ayant subi un TCCL. Les résultats des articles présentés dans cette thèse démontrent que le TCCL en soi peut nuire au fonctionnement attentionnel, puisque des déficits de l’attention peuvent être observés sur des tâches neuropsychologiques qui mesurent les temps de réaction avec précision. Des variables concomitantes au TCCL peuvent aussi avoir un impact négatif sur l’attention sélective; la présence de symptômes de douleur nuit à la performance sur des tâches d’attention et certains traits de personnalité sont associés à l’efficacité attentionnelle ou aux symptômes post-commotionnels. Cette thèse montre donc que divers facteurs peuvent contribuer aux difficultés d’attention des personnes ayant subi un TCCL. Le neuropsychologue devrait utiliser des tâches sensibles aux atteintes, parfois plus subtiles, que présentent les personnes ayant eu un TCCL lorsqu’il tente de comprendre les difficultés attentionnelles de cette clientèle. De plus, les variables associées à la douleur et certains traits de personnalité devraient être systématiquement évalués lors de l’examen neuropsychologique post-TCCL. / The main goal of this thesis is to study the multifactorial nature of attentional difficulties presented by individuals having sustained a mild traumatic brain injury. Specifically, we sought to determine how pain symptoms, emotional factors, and personality variables impact attentional functioning following mild traumatic brain injury. To achieve this, the present thesis describes the findings of three articles. In the first article we reviewed studies that had investigated the cognitive/neuropsychological impact of pain symptoms, and of psychological variables related to chronic pain. The second article presents the findings of an experimental study in which we explored the relationships between symptoms of pain, emotional factors, and attentional functioning in individuals with mild traumatic brain injury in different phases of recovery. A third article describes the results of another experimental study exploring the associations between personality variables, and attentional efficacy in both normal individuals and in those having sustained a mild traumatic brain injury. Findings of the studies described in this thesis demonstrate that mild traumatic brain injury can decrease attentional efficacy, as attentional deficits can be observed on certain neuropsychological tasks that precisely measure reaction times. Variables concomitant to mild traumatic brain injury can also negatively impact attention; the presence of pain symptoms is associated with decreased performance on attention tasks, and certain personality traits are associated with attentional efficacy or with post-concussion symptoms. This thesis thus demonstrates that various factors contribute to the attentional difficulties presented by persons with mild traumatic brain injury. The neuropsychologist should opt to use cognitive tasks sensitive to mild brain injury when exploring the attentional complaints of these individuals. As well, a thorough evaluation of variables related to pain, and of personality traits should be systematically conducted in the context of a post-MTBI neuropsychological examination.

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal.

L’objectif principal de cette thèse était d’obtenir, via l’électrophysiologie cognitive, des indices de fonctionnement post-traumatisme craniocérébral léger (TCCL) pour différents niveaux de traitement de l’information, soit l’attention sélective, les processus décisionnels visuoattentionnels et les processus associés à l’exécution d’une réponse volontaire. L’hypothèse centrale était que les mécanismes de production des lésions de même que la pathophysiologie caractérisant le TCCL engendrent des dysfonctions visuoattentionnelles, du moins pendant la période aiguë suivant le TCCL (i.e. entre 1 et 3 mois post-accident), telles que mesurées à l’aide d’un nouveau paradigme électrophysiologique conçu à cet effet. Cette thèse présente deux articles qui décrivent le travail effectué afin de rencontrer ces objectifs et ainsi vérifier les hypothèses émises. Le premier article présente la démarche réalisée afin de créer une nouvelle tâche d’attention visuospatiale permettant d’obtenir les indices électrophysiologiques (amplitude, latence) et comportementaux (temps de réaction) liés aux processus de traitement visuel et attentionnel précoce (P1, N1, N2-nogo, P2, Ptc) à l’attention visuelle sélective (N2pc, SPCN) et aux processus décisionnels (P3b, P3a) chez un groupe de participants sains (i.e. sans atteinte neurologique). Le deuxième article présente l’étude des effets persistants d’un TCCL sur les fonctions visuoattentionelles via l’obtention des indices électrophysiologiques ciblés (amplitude, latence) et de données comportementales (temps de réaction à la tâche et résultats aux tests neuropsychologiques) chez deux cohortes d’individus TCCL symptomatiques, l’une en phase subaigüe (3 premiers mois post-accident), l’autre en phase chronique (6 mois à 1 an post-accident), en comparaison à un groupe de participants témoins sains. Les résultats des articles présentés dans cette thèse montrent qu’il a été possible de créer une tâche simple qui permet d’étudier de façon rapide et peu coûteuse les différents niveaux de traitement de l’information impliqués dans le déploiement de l’attention visuospatiale. Par la suite, l’utilisation de cette tâche auprès d’individus atteints d’un TCCL testés en phase sub-aiguë ou en phase chronique a permis d’objectiver des profils d’atteintes et de récupération différentiels pour chacune des composantes étudiées. En effet, alors que les composantes associées au traitement précoce de l’information visuelle (P1, N1, N2) étaient intactes, certaines composantes attentionnelles (P2) et cognitivo-attentionnelles (P3a, P3b) étaient altérées, suggérant une dysfonction au niveau des dynamiques spatio-temporelles de l’attention, de l’orientation de l’attention et de la mémoire de travail, à court et/ou à long terme après le TCCL, ceci en présence de déficits neuropsychologiques en phase subaiguë surtout et d’une symptomatologie post-TCCL persistante. Cette thèse souligne l’importance de développer des outils diagnostics sensibles et exhaustifs permettant d’objectiver les divers processus et sous-processus cognitifs susceptible d’être atteints après un TCCL. / The main objective of this thesis was to obtain, using cognitive electrophysiology, biomarkers of mild traumatic brain injury (TBI) for different levels of information processing such as selective attention, visuo-attentional decision making and processes associated with the execution of a deliberate response. The fundamental assumption was that the lesion-producing mechanisms as well as the pathophysiology associated with mTBI leads to visuo-attentional dysfunctions, at least during the sub-acute period following the mTBI (i.e. between 1 and 3 months post-trauma), as measured by a novel electrophysiological paradigm developed for this purpose. This thesis presents two articles describing the work accomplished to meet these objectives, and verify the underlying assumptions. The first article presents the approach used to create a novel visuo-spatial attention task enabling the identification of electrophysiological (amplitude, latency) and behavioural (reaction time) indexes related to early visual and attentional processing (P1, N1, N2-nogo, P2, Ptc), selective visual attention (N2pc, SPCN) and decision-making processes (P3b, P3a) in a group of normal participants (i.e. without neurological injury). The second article presents a study of the persisting effects of a mTBI on visuo-attentional functions through the identification of targeted electrophysiological markers (amplitude, latency), and from behavioural data (task-related reaction time and neuropsychological tests results) in two cohorts of symptomatic mTBI individuals, one during the sub-acute phase (3 first months post-injury), the other during the chronic phase (6 months to 1 year post-injury), in comparison to a group of normal control participants. The results presented in this thesis indicate that it was has been possible to create a simple, rapid and low-cost task enabling the study of the various levels of information processing involved in the deployment of visuospatial attention. Subsequently, the use of this task in patients with mTBI tested during the sub-acute phase or the chronic phase allowed to identify differential impairment and recovery profiles for each of the components studied. Indeed, while the early components associated with early visual information processing (P1, N1, N2) were intact, certain attentional (P2) and cognitive-attentionnal (the P3a, P3b) components were affected, suggesting dysfunction in the spatio-temporal dynamics of attention, orientation of attention, and working memory, in the short- and/or long-term following mTBI, this is the presence of neuropsychological deficits mostly in the sub-acute phase and of persisting post-mTBI symptomatology. This thesis emphasizes the importance of developing sensitive and comprehensive diagnostic tools allowing to objectively identify the various cognitive processes and sub-processes that are likely to be affected after a mTBI.

L’objectif principal de la présente thèse est d’étudier la nature multifactorielle des difficultés attentionnelles que présentent les personnes ayant subi un traumatisme craniocérébral léger (TCCL). Plus spécifiquement, nous avons voulu cerner l’impact des symptômes de douleur, ainsi que de facteurs émotifs et de personnalité, sur le fonctionnement attentionnel de personnes ayant eu un TCCL. Afin d’atteindre cet objectif, cette thèse présente trois articles. Dans le premier article, l’impact cognitif/neuropsychologique de la douleur chronique (DC) et de ses variables psychologiques concomitantes a été examiné par le biais d’une recension des écrits. Le deuxième article présente une étude expérimentale portant sur les relations entre des variables liées à la douleur et à l’affectivité, et le fonctionnement attentionnel de personnes ayant subi un TCCL étant à différents stades de récupération, comparativement à un groupe témoin normal. Enfin, un troisième article décrit une étude expérimentale qui a été menée afin d’explorer les associations entre certains facteurs de personnalité (neuroticisme, extraversion) et l’efficacité attentionnelle chez des participants normaux, ainsi que chez des personnes ayant subi un TCCL. Les résultats des articles présentés dans cette thèse démontrent que le TCCL en soi peut nuire au fonctionnement attentionnel, puisque des déficits de l’attention peuvent être observés sur des tâches neuropsychologiques qui mesurent les temps de réaction avec précision. Des variables concomitantes au TCCL peuvent aussi avoir un impact négatif sur l’attention sélective; la présence de symptômes de douleur nuit à la performance sur des tâches d’attention et certains traits de personnalité sont associés à l’efficacité attentionnelle ou aux symptômes post-commotionnels. Cette thèse montre donc que divers facteurs peuvent contribuer aux difficultés d’attention des personnes ayant subi un TCCL. Le neuropsychologue devrait utiliser des tâches sensibles aux atteintes, parfois plus subtiles, que présentent les personnes ayant eu un TCCL lorsqu’il tente de comprendre les difficultés attentionnelles de cette clientèle. De plus, les variables associées à la douleur et certains traits de personnalité devraient être systématiquement évalués lors de l’examen neuropsychologique post-TCCL. / The main goal of this thesis is to study the multifactorial nature of attentional difficulties presented by individuals having sustained a mild traumatic brain injury. Specifically, we sought to determine how pain symptoms, emotional factors, and personality variables impact attentional functioning following mild traumatic brain injury. To achieve this, the present thesis describes the findings of three articles. In the first article we reviewed studies that had investigated the cognitive/neuropsychological impact of pain symptoms, and of psychological variables related to chronic pain. The second article presents the findings of an experimental study in which we explored the relationships between symptoms of pain, emotional factors, and attentional functioning in individuals with mild traumatic brain injury in different phases of recovery. A third article describes the results of another experimental study exploring the associations between personality variables, and attentional efficacy in both normal individuals and in those having sustained a mild traumatic brain injury. Findings of the studies described in this thesis demonstrate that mild traumatic brain injury can decrease attentional efficacy, as attentional deficits can be observed on certain neuropsychological tasks that precisely measure reaction times. Variables concomitant to mild traumatic brain injury can also negatively impact attention; the presence of pain symptoms is associated with decreased performance on attention tasks, and certain personality traits are associated with attentional efficacy or with post-concussion symptoms. This thesis thus demonstrates that various factors contribute to the attentional difficulties presented by persons with mild traumatic brain injury. The neuropsychologist should opt to use cognitive tasks sensitive to mild brain injury when exploring the attentional complaints of these individuals. As well, a thorough evaluation of variables related to pain, and of personality traits should be systematically conducted in the context of a post-MTBI neuropsychological examination.

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal

Rugby is a popular sport in South Africa, and has been played by young boys from as early as seven years old (South African Rugby Union [SARU], 2011). Despite various physical health benefits, it carries a high risk for injury, especially head injury, and consequently has a high incidence of concussion (Alexander, 2009; Laubscher, 2006; Shuttleworth-Edwards, Smith & Radloff, 2008). It is common for 12 to 13 per cent of adolescent rugby players to report mild traumatic brain injury or concussion per season (Laubscher, 2006; Shuttleworth-Edwards et al., 2008). The true incidence is however considered to be higher, even as high as 70.4% (Shuttleworth-Edwards et al., 2008). Concussion, otherwise known as mild traumatic brain injury (mTBI) is described as a traumatically induced alteration in mental status, or traumatically induced cerebral dysfunction (Kraus, McArthur, Silvermand & Jayaraman, 1996) which may, or may not involve loss of consciousness (Quality Standards Subcommittee, American Academy of Neurology [AAN], 1997). The nature of concussion has traditionally been considered to be transient, and symptoms are usually resolved within a few days or weeks (Kirkwood et al., 2008; Taylor et al., 2010). However, when concussions are not fully resolved prior to players returning to the game, they may be vulnerable to second impact syndrome. This syndrome causes herniation and brain oedema, which may result in death (Patel, 2005), as has been reported in South African press (Alexander, 2009; South African Press Association [SAPA], 2012). Even without second impact syndrome, repeated concussions may render the brain neurocognitively vulnerable, leading to an array of short- and long-term cognitive symptoms (Alexander, 2009; Shuttleworth-Edwards et al., 2008). Short-term problems include difficulties with attention, focus and concentration; following multi-step instruction, engaging in mental problem-solving; verbal expression, receiving and processing verbal and visual information; maintaining effective levels of mental and physical energy; controlling mood; suppressing impulsive behaviours; initiating and maintaining productive interpersonal relationships with peers; engaging in meaningful conversation and participating in group activities (Jantz & Coulter, 2007). Short-term cognitive impairments due to repeated concussion have also been found, and include amongst the former symptoms, also problems with delayed memory, learning, social functioning, and abstract thinking (Anderson, Brown, Newitt & Hoile, 2011; Laubscher, 2006). Long-term sequelae follow when children did not return to their baseline level of functioning after three months (Kirkwood et al., 2008; Taylor et al., 2010). Long-term sequelae include problems with memory, visuo-motor processing, executive functioning, learning and abstract thinking (Anderson, 2002; Anderson et al., 2010; Horton et al., 2010; Lezak et.al., 2004; Shuttleworth-Edwards & Radloff, 2008). As mTBI is traditionally thought to be of transient nature, researchers tend to investigate moderate to severe TBI, rather than mTBI (Alexander, 2009; Anderson et al., 2010; Patel, 2005). This could easily lead to important facts about mTBI being missed or not acknowledged. Nevertheless, recent investigations are uncovering facts about mTBI that could transform the way in which we understand mTBI, providing increasing evidence that mTBI is more serious than widely believed (Blakemore, 2012; Maxwell, 2011; Toleda et al., 2012). However, there remains a lack of research investigating mTBI from a single cause. Considering the above information, the current study provides unique information about mTBI. It specifically investigated the long-term effects of mTBI on adolescents from a homogenous cause, which makes results more comparable. The importance of this study is highlighted in the face of evidence for the long-term effects of multiple concussions, that were sustained during school rugby, on academic achievement (Alexander, 2009; Laubscher, 2006).In the light of grey areas in existing research, the aim of this current study was to investigate whether there is a significant difference in academic achievement within and between two groups of adolescents that had either played rugby and sustained multiple concussions, or had not played rugby nor sustained any concussions, when measured at four points in time over six years. A retrospective data-analysis was performed on matched, controlled, prospective longitudinal data, which was obtained from a study that evaluated the impact of repeated mTBI on the cognitive and academic functioning of early adolescent rugby players over time (Alexander, 2009). This study elaborates on a subset of the previous data, adding the gr. 12 results for academic aggregate scores, to the previously reported academic dataset. Participants were selected from Alexander‟s study (2009), and had either played rugby and obtained two or more concussions (Rugby/Concussed (RC- group); n=17), or did not play rugby nor sustained any concussions (Non-rugby/Non-concussed (NRC-group); n=13). Academic aggregate scores from baseline (gr. 7) through gr. 12 were analysed using quantitative statistical measures. A normal probability plot determined that the data was distributed normally. Descriptive statistics were reported, where after repeated measures ANOVA‟s were conducted to determine the statistical significance of differences in academic scores between and within the groups over time. These results indicated that the NRC-group displayed statistically significant increase in academic achievement over time (p = .000), whereas the RC-group did not display any significant differences, despite displaying a downwards trend in achievement. The difference between the two groups was measured at its highest in gr. 12 (p = .003), indicating that the NRC-group performed statistically significantly better than the RC-group over time. However, a Pearson‟s correlation test revealed that the estimated IQ (Vocabulary subscale of the WISC-III) (Wechsler, 1991) had a positive correlation on academic achievement [r(34) = .54, p < .05)]. To control for the effect that this correlation had on the academic results, an ANCOVA was conducted. This analysis indicated a statistically significant difference in academic achievement between the two groups in gr.12 (p = .004), with a large effect size (d = 1.41), implicating practical significance. Findings consequently confirmed our hypothesis. The significant increase in academic achievement observed within the NRC-group over time, is consistent with what could be expected if the brain is allowed to develop normally without disruption such as mTBI (Blakemore, 2012; Horton et al., 2010). The finding that the RC group did not display statistically significant intra-group differences in academic achievement when measured over time, but that academic achievement followed a downward trend, is difficult to substantiate in the literature. The few research studies on the effect of cumulative concussion on young athletes do not isolate academic achievement as a variable (Iverson et al., 2004; Shuttleworth-Edwards et al., 2008). Further research into intra-group differences in this specific area of enquiry and population group is therefore necessary. Normal cognitive and brain development, maintains that the brain develops in a posterior to anterior direction, and the prefrontal regions which are vulnerable to concussion, develop last (Anderson, 2010; Blakemore, 2012; Lezak, 2004). Whereas the primary motor and sensory areas and areas for receptive and expressive language are fully developed by the age of ten years, the prefrontal brain areas that are responsible for more complex and abstract thought repertoires only start maturing in early adolescence and this development continues up to the age of 24 and even into the early 30s (Toleda et al., 2012). Injury to the developing brain at this critical stage of maturation may adversely affect the development of cognitive skills, preventing the child from acquiring the effective cognitive strategies needed for normal academic functioning and adequate academic achievement after TBI (Horton et al., 2010). However, if there is no insult to the brain, cognitive functions are expected to develop normally as a result of synaptic pruning and increased white-matter volume in the prefrontal cortex (Blakemore, 2012), making it likely that the maturation of these abilities will lead to greater cognitive and academic ability (Blakemore & Choudhury, 2006), such as seen for the NRC-group in this study. Limitations for this study include a small sample size and the testing of only one variable. It is therefore recommended that future studies include more variables, and aim at creating a larger, randomized sample size, possibly providing a more representative pool of participants to study this phenomenon in South African context. It is also advised that future studies consider using neuropsychological measures to test cognitive functioning. As previous studies have indicated specific impairment in executive functioning after TBI, it may be worth researching the effect of concussion on executive functioning more thoroughly (Anderson, 2002; Anderson et al., 2010; Horton et al., 2010). Further it may be valuable to consider using functional MRI studies to broaden existing knowledge about the interaction between pathophysiology and cognitive functioning This study also highly recommends that schools and rugby clubs catering for child and adolescent players reconsider the importance of implementing proper return to play protocols after players obtain concussions. / Thesis (MA (Clinical Psychology))--North-West University, Potchefstroom Campus, 2013